"We believe that the philosophy of integration rather than isolation
which, has been the underlying theme of development still holds good"
(Better Services
1975 par 2.17).

Better Services for the Mentally Ill, a 91 page 'White Paper' was
presented "by Barbara Castle, as Secretary of State at the DHSS, in
October 1975. It was nick-named "Castles in the Air" by one radical
group (COPE) because this long-term strategic document, pointing out the
general direction the Government "wanted services to take, was prefaced
with the statement that little progress could be made until the economic
situation improved (p iv).

The Paper placed its emphasis on the provision of a comprehensive
range of local services (described later) rather than the closure of
asylums:-

"...our main aim is not the closure or rundown of the mental illness
hospitals as such? but rather to replace them with a local and better
range of facilities. It will not normally be possible for a mental
hospital to be closed until the full range of facilities described"
(in the paper) "has been provided throughout its catchment area and
has shown itself capable of providing for newly arising patients a
comprehensive service independent of the mental hospital. Moreover,
even then, it will not be possible to close the hospital until
I it is no longer required for the long stay patients admitted to its
care before the local services came into operation" (par 11.5).

Given the economic situation the White Paper was exceptionally hazy about
time scales. Providing the local services it proposed required (at
November 1974 prices) an average annual capital expenditure of £30
million by the NHS and £8 million by councils over a 20 to 30 year
period (par 11.8). Councils had actually spent only about £3 million
in this field in 1974/1975 and although the NHS figure was about that
actually spent in 1972/1973, less bad been spent since the health cuts
(Priorities
1976 introduction and pars 8.9 + 8.10).

The White Paper said
investment on the scale needed would not be possible "over the next three
or four years" (par 11.5) but in 1976, by giving 'deprived sectors'
'priority' over general and acute hospital provision, a rate of development
was proposed which "if maintained" would enable the 'Better Services' aims
to be achieved over most of the country within 25 years
(Priorities
1976 introduction and pars 8.9 + 8.10).

Although perhaps not as clear as it might have been, one could deduce
from Better Services that many asylums were to maintain an active life
well into the 21st century, and the White Paper said (p 88, par l) that
they would contain the majority of patients "for many years to come".

The House of Commons was later told (*) that at the end. of 1975 only
8.1% of mental illness beds were in general hospitals so, presumably,
over 90% of in-patients were still in the old asylums. 30% of admissions,
however, were in District General Hospital units, so mental hospitals
clearly contained a disproportionate percentage of long stay patients.

During the (now long) transitional period to local services the health
authorities were to continue with a 1971 memorandum recommendation to
split asylums into "divisions" each serving the district in which
local facilities were being developed to replace it.

"In this way it
is hoped that staff will increasingly think...in terms of a district
service which, wherever it is provided, whether from a mental hospital
"division", a general hospital psychiatric unit, a community hospital,
or in...supportive work in the community itself, is all part of the
same district service." (PP 88-9, pars 3-5. See also HM(71)97, par 14)

The exact distinction between new and old is not clear. At least four
definitions - each involving a different
concept - appear to me explicit or implicit in the White Paper and its
associated literature. For old long-stay these are:-

Pragmatic Definition: Long-stay patients admitted, to a mental
hospital "before a comprehensive district psychiatric service is
established - a definition implicit in Better Services.

Humanitarian Definition: Patients so 'institutionalised' that it
would be 'inhuman' to discharge them. (See below)

Statistical Definition: People who have been in-patients for over
5 (or whatever) years. (WH0 1978, pp 8 + 57)

According to the 'White Paper a great deal of effort in the 1950s and 1960s
had been put into rehabilitation work with long-stay patients - but in
practice it had rarely proved possible to discharge to the community and
hospitals had lost interest in rehabilitating chronic patients (par 2.12).

Many old long-stay patients, it said, were not in hospital because they
needed specialist hospital services, but because:-

"they either need other forms of shelter and support which are at
present not available outside hospital, or have become so accustomed
to hospital life - in some cases so institutionalised - that it would
be inhuman to discharge them from the hospital that has in fact
become their home." (par 4.51)

The humanitarian argument was a superfluous gloss. Economic
considerations were to determine that old long-stay residents remained in
the asylums. The Government's
Priorities
paper in 1976 took pains to explain that the network of district services
outlined in Better Services was only intended to take over from the mental
hospitals the care and treatment of new patients. The scale of
facilities would not enable it

"to take over responsibility for the
diminishing group of 'old long-stay' patients".
(Priorities
1976 par 8.4)

Money was, however, to be spent maintaining the physical structure and
improving the standards of decoration, toilet and other facilities in
mental hospitals because this was "essential" to maintain the "morale of
the staff" and to ease the "burden of nursing an increasingly ageing
in-patient population"
(Better Services
1975 p 90 par 12).

The "New Long-Stay" Patients

It was the "new" long-stay - those who remained in hospital despite
modern treatment methods - that the "new pattern" of comprehensive local
services was intended, eventually, to benefit. Sir Keith Joseph had
spoken optimistically of "the small proportion of patients who will
require relatively longer stay" (EC Hansard 7/12/1971 col 280) but
Better Services pointed, out that:-

"While this group may be relatively few...the implications in terms of
resources are quite disproportionate to their numbers"
(Better Services
1975 par 1.16)

If of 100 patients entering a hospital, one remains for 10 years and the
others stay an average of only 5 weeks then the one long-stay patient
will use the same amount of bed-space as all the 99 short-stay patients.

An article in the British Medical Journal (7/3/1972) estimated that if
chronic patients represented only 1% of all acute hospital admissions,
after only 7 years they would have silted up half the beds in District
General Hospital Psychiatric Units. (Cited MIND/13, p 7)

Better Services quoted estimates (*) that about one in three of the
newly arising long-stay patients not suffering from dementia needed 24
hour medical and nursing supervision.

* The estimates appear to have been based on Wing, J.K., 1973» but
the 'White Paper also cited research the DHSS had commissioned by Dr
Sheila Mann and Mrs Wendy Cree (Mann, S.A. + Cree, V., 1976).

They were, predominantly,
patients diagnosed "chronic schizophrenic" - who were "particularly prone
to be slow, -withdrawn and liable to neglect themselves" (pars 4.52 +
4.53). 'Hospital' had to be 'home' as well for such patients and a
ward in a District General Hospital Psychiatric Unit could not provide a
sufficiently domestic
environment for patients who stayed more than a year (par 4.53).

The other two-thirds, with the exception of small numbers in special
categories, did not need hospital care, but were in hospital because the
long-term sheltered accommodation in the community they needed was
virtually non-existent (par 4.52 + Wing, J.K. 1973, P 30).

The White
Paper's
Guidelines for council
accommodation
repeated
guidelines issued in 1972 (DHSS 35/72 par 42) with the emphasis on long-
term accommodation instead of hostels. But the value of such guidelines
depended on councils taking note of them. As late as November 1979, my
local borough, Hackney, recorded in its social services minutes that the
difficulties of its new 20 bed hostel were due to consultants referring
"long-stay clients".

Hospital Hostels A suggested approach to the needs of long-stay
patients who needed residential accommodation with medical and nursing
supervision was a "Hospital Hostel" - a large house, reasonably close
to the psychiatric unit, in which residents could be cared for in a
domestic atmosphere, but with night nursing supervision. By day they
would go to the day hospital, to council day centres or, perhaps, to
sheltered work (pars 4.52 - 4.54).

The first (experimental) hospital-
hostel was established at the Maudsley Hospital, South London, in 1977
(Wing in Wing + Olsen, 1979, p.10).

The Elderly

Patients over 65 formed. 20-25% of admissions to mental illness hospitals
and units in 1975 (par 4.l0) and, as at Whittingham, their care was
mainly being left to the mental hospitals. Better Services suggested
priority development of local services for the elderly to counter the
emergence of this 'two-tier' system.

Assessment of elderly patients' needs should, wherever possible, take
place at home or in out-patient clinics because

"the physical uprooting
of an old person is in itself a traumatic experience" (par 4.10).

Where
this was not possible in-patient assessment should take place in a local
unit even where a District General Hospital psychiatric unit had not yet
been established - small 'joint assessment' units could be provided in the
geriatric department of the District General Hospital (par 4.11).

In its comments on the 1972
memorandum, MIND had stressed the importance of such units pointing out
that in one area only 10% of those admitted to a local assessment unit
were found to be in need of long term hospital care (MIND/9, p 4).

In the new pattern of services, hospital admission, where necessary,
would usually be to a psychiatric unit. In some districts a psychiatrist
with special responsibility for elderly people had been appointed and this
could facilitate links with geriatric physicians, G.Ps and social services
departments (par 4.10).

Community Hospitals for patients with severe dementia needed to be
developed in parallel with, if not ahead of, the District General Hospital
Psychiatric Unit so that the mental hospitals were not

"left to care for patients who make
heavy demands on nursing staff, often in unsatisfactory physical
conditions" (par 11.19).

The community hospitals would, normally contain
geriatric and psycho geriatric units for longer stay patients and the
geriatric unit would care for all patients who were significantly
physically ill including demented patients (par 4.15).

In such hospitals
the "interest of friends and relations and local communities" could be
more easily maintained, and the day to day care of patients could be
entrusted to local GPs (pars 4.13 + 4.15).

Adjoining the psychogeriatric unit there should, be a day hospital for
in-patients and patients living in the community (par 4.l6).

With respect to the care of the majority of the mentally infirm: those
living at home (or sometimes in old people's homes) the 'White Paper had
little to say. The DHSS was "examining the advantages and
disadvantages" of various local authority support schemes, "and may issue
guidance...in due course" (par 4.48).

The Future Pattern of Services.

The psychiatric scenario outlined in Better Services is illustrated by
the table (*) and diagram below.

* Based on the table in
Better Services
1975 (par 4.64) with the addition of
the figure for "Units for 'New Long-Stay' Patients" from the provisional
estimate in par 4.53.

GUIDELINES FOR SERVICES AT DISTRICT LEVEL
Rates per 100,000 population

Hospital Services

Beds

Day Places

District General Hospital
Psychiatric Unit

50

65

Units for elderly severely mentally infirm patients

30-40

25-40

Units for new long-stay patients under 65

17

Local Authority Services

Beds

Day Places

Hostels

4-6

Long-Stay Accommodation

15-24

Day Centres

60

The old asylum, or mental hospital, is outside the community:

It is a self-contained world on its own,
structuring every aspect of its inhabitants' existence day and night, day
after day; and, "because of its location, separating those who reside there
from the lives of families, friends and neighbours - what Goffman called,
in
Asylums, a
Total
Institution.

This is to be replaced by the range
of local facilities shown, although even then the "old long-stay"
residents would remain in the asylum.

In the future pattern of services, hospital facilities be local,
and in-patient treatment avoided.

Where in-patient treatment was unavoidable,
and care continued for any length of time, there would be a distinction
between where the patient resided and where he or she spent the
day.

The
psychiatric unit, for example, was to have "two main functional
components":

wards, "or rather residential units", and

a "day activity
area".

The great majority of in-patients would

"spend the day on a
planned programme in the day hospital...thus having the stimulation of...
a pattern of living which more closely resembles normal everyday life"
(par 4.3)

A range of day-time and evening facilities, including local authority
day centres, sheltered employment schemes and social clubs, would be
required for those living in community accommodation. These would assist
people to maintain an independent life outside hospital and, in some
cases, relieve the strain on families of their living at home. (par 4.28)

In addition to the District level facilities there would be required on a
Regional basis: a 'Regional Secure Unit' (2 beds per 100,000 population)
for patients too disruptive to be accommodated in a District General
Hospital ward, and units
for mentally disturbed children and adolescents (2.25 beds per 100,000
population for each). (Better Services
1975 par 4.63. Norms taken from other
sources).

From Medical to Social Provision

The importance of the strategy outlined in
Better Services
1975 was that it did
not rely on an unrealistic belief in psychiatry's power to "cure" mental
disability. The comprehensive provision it envisaged included long-term
social care for the 'chronic' cases acute psychiatry had been sending to
the mental hospitals.

Hospital staff, the paper noted, saw a hospital's role as an "active
therapeutic one" and were increasingly unwilling to be "social care
custodians" but facilities for social care outside hospital were "not
generally available" (par 2.8). "For 16 years or more" Dr David Owen
told MPs "we have all...paid lip service" to the concept of caring for
most of the mentally ill in the community, but the White Paper showed that,
whilst nearly £300 million (*) was
spent
on hospital services for the mentally ill, in 1973-4 only about £.15
million (*) was spent on Social Services (HC Hansard. 26/1/1976 col 35).
The Government intended to see that, over a period of years, "the balance
of health and social services" was "put right" (par 2.8).

The Government's four main objectives were to expand council services, to
move specialist (hospital) services to local settings, to establish the
right organisational links between sectors and to improve staffing levels
(par 2.22). Alison Wertheimer commented in MIND's magazine that
establishing the right links was the objective that "poses the greatest
difficulties and the greatest hopes" :-

"The crucial factor in the achievement of the.. .service envisaged.... is
going to be successful joint planning between health and social
services coupled with a shift in resources from the health sector to
... social services." (Mind Out, December 1975 p.12).

JANUARY 1976: THE BIRMINGHAM SCANDAL.

Between 1970 and 1975 the population of mental illness hospitals was
reduced from 107,977 to 87 .,321 and that of mental handicap hospitals from
55,434 to 49,683 (**).

But how had this been achieved? Some argued it
was by discharging patients to families ill-equipped to cope with them,
to private 'hotels' that exploited them, or onto the streets.

"the public...cannot be expected to tolerate under the name of
community care the discharge of chronic patients without...after-
care...who perhaps spend their days wandering the streets or become
an unbearable burden on the lives of their relatives..• Such
situations do not occur very frequently: but where they do, the
whole concept of community care is placed at risk" (par 2.27)*